Ch. 29 Chronic Right Hand Pain

Question 1

What is the differential diagnosis?

What is the most likely dx?

Answer 1

Carpal tunnel syndrome

Question 2

What are the best known classic signs of carpal tunnel syndrome?

Answer 2

Tinel’s sign & Phalen’s test

Tinel’s sign = elicited by gently percussing over the median nerve at the carpal tunnel… a positive sign is present if the pt describes an electrical shock sensation in the median nerve distribution

Phalen’s test is performed by having the pt place the dorsal sides of each hand against each other in a position of maximal wrist flexion for 30-60 s. The test is considered positive if the pt reports new or worsening paresthesias in the median nerve distribution of the affected hand(s).

Both tests have variable sensitivity and specificity.

Question 3

What other overlapping median nerve diagnoses should be considered?

Answer 3

• Pronator syndrome (proximal median nerve compression at elbow)
• Acute carpal tunnel syndrome
• Traumatic median nerve injury
• Median nerve tumor (e.g., schwannoma)

Question 4

What physical exam finding helps distinguish proximal median nerve compression at the elbow from compression at the carpal tunnel?

Answer 4

Palmar cutaneous branch of median nerve branches prior to the carpal tunnel and travels above the transverse carpal ligament… It innervates the skin over the thenar eminence

Thus, typical CTS will not show sensory dysesthesias in this area whereas pronator syndrome will.

Question 5

What findings help distinguish CTS from cervical spine root pathology?

Of note re: C6 and C7 nerve roots

Answer 5

Much like the straight leg raise for sciatica of the lumbar spine, Spurling’s test may be used to elicit cervical root pathology (radiculopathy).

The pt is asked to extend the neck, tilt and turn the head laterally to the affected side to determin if the hand dysesthesias occur or worsen with the maneuver

Of note re: C6 and C7 nerve roots:

C6 and C7 nerve rootes overlap the median nerve distribution to the hand and are often confused with it. A key sensory distinction is that CTS does NOT affect the dorsal hand except for the finger tips. C6 and C7 nerve roots also affect the dorsum of the hand in the radial nerve distribution in addition to the median distribution.

Question 6

What systemic condition is often associated with CTS?

Answer 6

Hypothyroidism

Question 7

If a patient cannot have an MRI due to incompatiable stent, pacemaker, etc… what is the test of choice for spinal pathology?

Answer 7

CT myelogram

(dural puncture and injection of contrast into the thecal sac to outline the spinal cord and nerve roots)

Question 8

Initial treatment for CTS?

Answer 8

Splinting of the wrist (not hand) in neutral position

+NSAIDs and activity modifications

Question 9

Failure to recognize spinal pathology: CTS vs myelopathy

Answer 9

Myelopathy = largely irreversible and may lead to paralysis if masquerading as CTS

Both CTS and myelopathy often present with hand numbness or tingling and complaints of dropping things.

For myelopathy, check for hyperreflexia, gait imbalance and ask about hand incoordination like deterioration in fine motor skills.